NCD Planning: Current Status & Opportunities for Stroke

Feisul Idzwan Mustapha MBBS, MPH, AM(M)Public Health Physician, NCD Section, Disease Control Division

Ministry of Health, Malaysia

Asia Pacific Meeting 18 October 2014

Kuala Lumpur

dr.feisul@moh.gov.my

Ministry of Health Malaysia

First High-level Meeting on NCDs (New York, 19-20 September 2011) 2011

Second high-level Meeting on NCDs (New York, 10-11 July 2014) to take stock of the progress made since 2011

2014

Third High-level Meeting on NCDs to report on progress achieved since 2014

2018

Outcome Document of the 2014 UN General Assembly High-level Meeting on NCDs

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2014 UN Outcome Document on NCDs(resolution A/RES/68/300)• Bottom line:

Governments committed themselves to intensify their efforts towards a world free of the avoidable burden of NCDs

• Moving forward: Maps out a set of concrete national commitments to be implemented between 2014 and 2018, and provides 3 new global assignments

• Towards the world we want: Next milestone in 2018

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National commitments included in the 2014 UN Outcome Document on NCDs

By 2015, consider setting national targets for NCDs

By 2015, consider developing national multisectoral policies and plans

Integrate NCDs into health-planning and national development plans

By 2016, implement "best buys" to reduce risk factors for NCDs

By 2016, implement "best buys" to enable health systems to respond

Strengthen national surveillance systems4

Global assignments included in the 2014 UN Outcome Document on NCDs

By 2015, WHO to develop an approach to register and publish contributions of non-State actors towards the 9 global NCD targets

WHA68: Framework for country action to mobilize sectors beyond health

OECD/DAC: Purpose code to track development assistance for NCDs

By 2017, WHO to submit a progress report to UN General Assembly

By 2018, UN General Assembly to convene a third High-level Meeting

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Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

Global accountability framework for NCDs:Milestones during the next three years

• WHO publishes global baseline• WHO conducts third survey on national

capacities• WHO generates data

2015

• Progress report to WHA on 25 outcome indicators

• Progress report to WHA on 9 progress indicators

2016

• Independent evaluation (Global Action Plan)• Progress report to the UN General Assembly

2017 6

Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

NCDs in the post-2015 development agenda: Towards the world we want• 10 September 2014: Member

States welcomed the report of the Open Working Group of the UN General Assembly on Sustainable Development Goals

• Next 12 months: Proposal shall be the main basis for integrating sustainable development goals into the post-2015 development agenda

• Target 3.4: By 2030 reduce by one-third pre-mature mortality from NCDs through prevention and treatment, and promote mental health and well-being

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Slide courtesy of Dr Shin Hai-rim, WHO Western Pacific Region Office

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Cost effective interventions to address NCDs

Population-based interventions addressing NCD risk factors 

Tobacco use  

- Excise tax increases - Smoke-free indoor workplaces and public places- Health information and warnings about tobacco - Bans on advertising and promotion

Harmful use of alcohol

- Excise tax increases on alcoholic beverages - Comprehensive restrictions and bans on alcohol

marketing- Restrictions on the availability of retailed alcohol

Unhealthy diet and physical inactivity

- Salt reduction through mass media campaigns and reduced salt content in processed foods

- Replacement of trans-fats with polyunsaturated fats- Public awareness programme about diet and physical

activity

Individual-based interventionsaddressing NCDs in primary care 

Cancer - Prevention of liver cancer through hepatitis B immunization

- Prevention of cervical cancer through screening (visual inspection with acetic acid [VIA]) and treatment of pre-cancerous lesions

CVD and diabetes

- Multi-drug therapy (including glycaemic control for diabetes mellitus) for individuals who have had a heart attack or stroke, and to persons at high risk (> 30%) of a cardiovascular event within 10 years

- Providing aspirin to people having an acute heart attack

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Cost effective NCD interventions…

• What works, what can we afford, and what should we adopt?

• The challenge? Identify interventions that:• are effective;• can lead to measurable declines in NCD death rates

quickly (e.g. over 10 years);• are affordable; and• can easily be implemented and sustained.

The Lancet. December 8, 2007 Volume 370:Gaziano T, Galea G and Reddy K. Scaling up interventions for chronic disease prevention: the evidence. pp 1939-1946.

The Lancet. December 15, 2007. Volume 370:Asaria P, Crisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. pp 2044-2053.Lim S, et. al. Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income countries: health effects and costs. pp 2054-2061.

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Cost effective NCD interventions…

• What is effective? The intervention must:• targets behaviours or risk factors that are causally

associated with NCDs; and• is proven, through evidence, to lead to favourable

changes in behaviours/risk factors, thereby reducing risk of death from NCDs.

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Source of icons: World Heart Federation Champion Advocates Programme

Global NCD Targets

Proportional mortality, Malaysia (% of total deaths, all ages, both sexes)

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Premature mortality due to NCDs, Malaysia

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The probability of dying between ages 30 and 70 years from the 4 main NCDs is 20%

DALYs attributable to risk factors

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10.8%

10.7%

9.0%8.3%

5.2%4.3%

3.1%0.7%

0.1%

10.8%

0.7%11.4%

12.1%

5.1%0.9%

4.3%0.7%

0.1%

15.0% 10.0% 5.0% 0.0% 5.0% 10.0% 15.0%

High BP

Tobacco

Diabetes Mellitus

High BMI

High Cholesterol

Alcohol

Physical Inactivity

UnderweightPoor Water & Sanitation

Male Female

Burden of Disease Study Malaysia, slide courtesy of Dr Mohd. Azahadi Omar, Institute for Public Health

19.4%

15.7%

8.5%

7.3%

7.0%

5.0%

2.3%

0.2%

0.1%

22.8%

1.2%

9.1%

8.1%

8.2%

7.1%

0.3%

0.2%

0.1%

25% 20% 15% 10% 5% 0% 5% 10% 15% 20% 25%

High BP

Tobacco

Diabetes Mellitus

High Cholesterol

High BMI

Physical Inactivity

Alcohol

Underweight

Poor Water & Sanitation

Male Female

Deaths attributable to risk factors

Burden of Disease Study Malaysia, slide courtesy of Dr Mohd. Azahadi Omar, Institute for Public Health

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National Systems Response to NCDs – ASEAN Countries

BRN

CAM

IND

LAO

MAL

MYN

PHI

SIN

THA

VIET

Has an operational NCD unit/branch or department within MOH ✓ ✓ ✓ ✗ ✓ ✗ ✓ ✓ ✓ ✗Has an operational multisectoral & integrated national policy, strategy or action plan ✗ ✗ ✓ ✗ ✓ ✓ ✗ ✗ ✗ ✗Has an operational policy, strategy or action plan to reduce the harmful use of alcohol ✓ ✓ ✓ ✗ ✗ ✓ ✓ ✗ ✓ ✗Has an operational policy, strategy or action plan to reduce physical inactivity ✗ ✓ ✓ ✗ ✓ ✓ ✓ ✓ ✓ ✗Has an operational policy, strategy or action plan to reduce the burden of tobacco use ✗ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓Has an operational policy, strategy or action plan to reduce unhealthy diet and/or promote healthy diets ✗ ✓ ✓ ✗ ✓ ✓ ✓ ✓ ✓ ✓Has evidence-based national guidelines for the Mx of major NCDs through a primary care approach ✓ ✗ ✓ ✗ ✓ ✓ ✗ ✓ ✓ ✗Has an NCD surveillance and monitoring system in place to enable reporting for the GMF ✗ ✓ ✗ ✗ ✓ ✗ ✗ ✓ ✓ ✓Has a national, population-based cancer registry ✓ ✗ ✗ ✗ ✗ ✗ ✗ ✓ ✗ ✗

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Global Action Plan for the Prevention and Control of NCDs 2013-2020Has six (6) objectives:

1. To raise the priority accorded to the prevention and control of NCDs in global, regional and national agendas and internationally agreed development goals, through strengthened international cooperation and advocacy.

2. To strengthen national capacity, leadership, governance, multi-sectoral action and partnerships to accelerate country response for the prevention and control of NCDs.

3. To reduce modifiable risk factors for NCDs and underlying social determinants through creation of health-promoting environments.

4. To strengthen and orient health systems to address the prevention and control of NCDs and the underlying social determinants through people-centred primary health care and universal health coverage.

5. To promote and support national capacity for high-quality research and development for the prevention and control of NCDs.

6. To monitor the trends and determinants of NCDs and evaluate progress in their prevention and control.

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National Strategic Plan for Non-Communicable Diseases (NSP-NCD) 2010-2014

• Presented and approved by the Cabinet on 17 December 2010.

• Provides the framework for strengthening NCD prevention & control program in Malaysia.

• Adopts the “whole-of-government” and “whole-of-society approach”.

• Diabetes & obesity are used as the entry points.

Seven Strategies:1. Prevention and

Promotion2. Clinical Management3. Increasing Patient

Compliance4. Action with NGOs,

Professional Bodies & Other Stakeholders

5. Monitoring, Research and Surveillance

6. Capacity Building7. Policy and Regulatory

interventions

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Multi-disciplinary care team

Post-basic training for paramedics

Clinical practice guidelines

Quality improvement

programs

Clinical information

systems

Patient resource centres

Community empowerment

Strengthening Chronic Disease Management at the primary care level

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Availability of essential medicines

The challenges of access to essential medicines for NCDs:

1. generic oral medicines available cheaply on the international market but intermittently available in countries and of uneven quality;

2. asthma inhalers and insulin available at high cost, and quality assessment being highly challenging;

3. NCD medicines still under patent and accessible only through expanded access programmes; and

4. opioid analgesics for palliative care often limited by excessive regulation.

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David Beran, Christophe Perrin, Nils Billo, John S Yudkin. 2014. Improving global access to medicines for non-communicable diseases. The Lancet Global Health. Volume 2, Issue 10

Availability of essential medicines• Global initiatives have shown that it is possible to deliver care and

medicines for a complex chronic disease in low-income and middle-income countries, for AIDS and TB.

• Two NCD schemes might provide pointers for future directions. • The Global Task Force on Expanded Access to Cancer Care and Control

helps with delivery of affordable cancer drugs, vaccines, and services through assistance with finance and procurement.

• The Asthma Drug Facility established and run by International Union Against Tuberculosis and Lung Disease has assisted low- and middle-income countries to reduce by half the cost of quality-assured asthma inhalers through a quality assurance system based on WHO standards and a transparent tendering process.

• Combining these initiatives as a basis for an NCD Drug Information Facility might offer an attractive route to improve the international availability and affordability of quality generic medicines for NCDs. 23

David Beran, Christophe Perrin, Nils Billo, John S Yudkin. 2014. Improving global access to medicines for non-communicable diseases. The Lancet Global Health. Volume 2, Issue 10

Lessons learned from the past and current attempts to work with other sectors• Go for the path of least resistance.

• Perhaps less impact, but at least establish the link and develop trust.

• Compromise, find the “middle path”• You cannot force the other sectors to go 100% your way.

• Be creative – think “out-of-the-box”• Use other existing mechanisms not previously used to move the

NCD prevention and control agenda forward.• Be sensitive to current global/national trends.

• Use any opportunity to move the NCD prevention agenda forward.

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threestepsmutuality of interest

specificity of purpose

identification of specific resources

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Thank you

dr.feisul@moh.gov.my

Facebook: Feisul Mustapha

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